Détails:USAir Flight 1493 left Columbus at 13:17 for a flight to Los Angeles. The Boeing 737 aircraft entered LAX airspace around 17:57 and was cleared for a CIVET Two Profile Descent and ILS runway 24R approach. At 17:59 this was changed to a runway 24L approach clearance.At about the same time a SkyWest Metro II aircraft (Flight 5569 to Palmdale) taxied out from Terminal 6, Gate 32 to runway 24L. At 18:03 the crew were advised to "taxi up to and hold short of 24L" because of other traffic. At 18:04:49 the flight was cleared to taxi into position and hold. Immediately thereafter the controller became preoccupied with instructing WingsWest Flight 5006 who had unintentionally departed the tower frequency. The WingsWest 5072 reporting ready for takeoff caused some confusion because the controller didn't have a flight progress strip in front of her. The strip appeared to have been misfiled at the clearance delivery position. Meanwhile, Flight 5569 was still on the runway at the intersection with taxiway 45, awaiting takeoff clearance.At 18:07 Flight 1493 touched down. Simultaneous to the nosegear touchdown, the Boeing 737 collided with the SkyWest Metro. Both aircraft caught fire and slid to the left into an unoccupied fire station.

Probable Cause:

PROBABLE CAUSE: "The failure of the Los Angeles Air Traffic Facility Management to implement procedures that provided redundancy comparable to the requirements contained in the National Operational Position Standards and the failure of the FAA ATS to provide adequate policy direction and oversight to its ATC facility managers. These failures created an environment in the Los Angeles ATC tower that ultimately led to the failure of the Local Controller 2 (LC2) to maintain awareness of the traffic situation, culminating in the inappropriate clearances and the subsequent collision of the USAir and SkyWest aircraft. Contributing to the cause pf the accident was the failure of the FAA to provide effective quality assurance pf the ATC system."

MODIFY AIR TRAFFIC CONTROL PROCEDURES AT THE LOS ANGELES INTERNATIONAL AIRPORT TO (Closed - Acceptable Action)

Issued: 03-DEC-1991

To: FAA

A-91-105

UNDERTAKE A THOROUGH RISK-BASED EVALUATION OF AIR TRAFFIC CONTROL PROCEDURES AT THE LOS ANGELES INTERNATIONAL AIRPORT, EVALUATE WHETHER CHANGES ARE REQUIRED, AND IMPLEMENT NECESSARY CHANGES. THE EVALUATION SHOULD CONSIDER AT LEAST THE FOLLOWING ISSUES (Closed - Acceptable Action)

Issued: 03-DEC-1991

To: FAA

A-91-106

INCLUDE IN THE OFFICE OF SAFETY QUALITY ASSURANCE THE AUTHORITY AND RESOURCES TO (Closed - Unacceptable Action)

Issued: 03-DEC-1991

To: FAA

A-91-107

RETAIN THE NATIONAL OPERATIONAL POSITION STANDARDS AS A SEPARATE, INDEPENDENT ORDER AND (Closed - Unacceptable Action)

Issued: 03-DEC-1991

To: FAA

A-91-108

PROVIDE AIR TRAFFIC CONTROL SUPERVISORS WITH FORMAL TRAINING TO IMPROVE THEIR UNDERSTANDING OF THE INTENT, OBJECTIVES AND ADMINISTRATION OF THE TECHNICAL APPRAISAL PROGRAM. (Closed - Acceptable Action)

Issued: 03-DEC-1991

To:

A-91-109

THE NTSB RECOMMENDS THAT THE FEDERAL AVIATION ADMINISTRATION. REQUIRE THAT INTERIM EVALUATIONS OF CONTROLLER PERFORMANCE, SUCH AS THOSE OF THE TECHNICAL APPRAISAL PROGRAM, BE RETAINED FOR 2 YEARS AND UTILIZED IN CONJUCTION WITH OTHER PERFORMANCE APPRAISALS TO TRACK THE PERFORMANCE AND TRAINING NEEDS OF AIR TRAFFIC CONTROLLERS. (Closed - Acceptable Action)

Issued: 03-DEC-1991

To: FAA

A-91-110

CONDUCT A ONE-TIME EXAMINATION OF THE AIRPORT LIGHTING AT ALL U.S. TOWER-CONTROLLED AIRPORTS TO ELIMINATE OR REDUCE RESTRICTIONS TO VISIBILITY FROM THE CONTROL TOWER TO THE RUNWAYS AND OTHER TRAFFIC MOVEMENT AREA. (Closed - Acceptable Action)

Issued: 03-DEC-1991

To: FAA

A-91-111

REDEFINE THE AIRPLANE CERTIFICATION COVERAGE COMPLIANCE STANDARDS FOR ANTICOLLISION LIGHT INSTALLATIONS TO ENSURE THAT THE ANTICOLLISION LIGHT(S) OF AN AIRRAFT IN POSITION ON A RUNWAY ARE CLEARLY VISIBLE TO THE PILOT OF ANOTHER AIRCRAFT PREPARING TO LAND OR TAKE OFF ON THAT RUNWAY. (Closed - Unacceptable Action)

Issued: 03-DEC-1991

To: FAA

A-91-112

EVALUATE AND IMPLEMENT, AS APPROPRIATE, SUITABLE MEANS FOR ENCHANCING THE CONSPICUITY OF AIRCRAFT ON AIRPORT SURFACES DURING NIGHT OR PERIODS OF REDUCED VISIBILITY. INCLUDE IN THIS EFFORT MEASURES, SUCH AS THE DISPLACEMENT OF AN AIRCRAFT AWAY FROM THE RUNWAY CENTERLINE, WHERE APPLICABLE, AND THE USE OF CONSPICUITY ENHANCEMENTS, SUCH AS HIGH-INTENSITY STROBE LIGHTING AND LOGO LIGHTING BY AIRCRAFT ON ACTIVE RUNWAYS, AND ENCOURAGE OPERATORS OF AIRPLANES CERTIFICATED PRIOR TO SEPTEMBER 1, 1977, TO UPGRADE THEIR AIRPLANES TO THE PRESENT HIGHER INTENSITY STANDARDS FOR ANTICOLLISION LIGHT INSTALLATIONS. (Closed - Unacceptable Action)

Issued: 03-DEC-1991

To: FAA

A-91-113

DIRECT THE GENERAL AVIATION COMMUNITY AND THE AIRLINES TO TAKE STEPS TO ENSURE THAT PILOT TRAINING PROGRAMS, INCLUDING COCKPIT RESOURCE MANAGEMENT TRAINING AND FLIGHT OPERATIONS PROCEDURES, PLACE SUFFICIENT EMPHASIS ON THE NEED FOR PILOTS TO MAINTAIN VIGILANCE IN MONITORING AIR TRAFFIC CONTROL RADIO COMMUNICATION FREQUENCIES FOR POTENTIAL TRAFFIC CONFLICTS WITH THEIR AIRCRAFT, ESPECIALLY WHEN ON ACTIVE RUNWAY AND/OR WHEN CONDUCTING A FINAL APPROACH TO A LANDING. (Closed - Acceptable Action)

Issued: 03-DEC-1991

To: FAA

A-91-114

INCORPORATE INTO THE AIRMAN\'S INFORMATION MANUAL LANGUAGE THAT WILL ALERT PILOTS TO THE NEED FOR VIGILANCE IN MONITORING AIR TRAFFIC FREQUENCIES FOR TRAFFIC CONFLICT SITUATIONS WHICH MAY AFFECT THE SAFETY OF THEIR FLIGHT. (Closed - Acceptable Action)

Issued: 03-DEC-1991

To: FAA

A-91-115

DEVELOP FOR INCLUSION IN THE AIRMAN\'S INFORMATION MANUAL AND THE AIR TRAFFIC CONTROL HANDBOOK (7110.65F) SPECIFIC PHRASEOLOGY TO BE USED BY PILOTS WHEN REQUESTING AN INTERSECTION DEPARTURE AND SPECIFIC PHRASEOLOGY TO BE USED BY CONTROLLERS WHEN ISSUING A POSITION-AND-HOLD CLEARANCE FOR AN INTERSECTION DEPARTURE. (Closed - Acceptable Action)

Issued: 03-DEC-1991

To: FAA

A-91-116

PROHIBIT THE USE, AFTER A SPECIFIED DATE, OF CABIN MATERIALS IN ALL TRANSPORT CATEGORY AIRPLANES THAT DO NOT COMPLY WITH THE IMPROVED FIRE SAFETY STANDARDS CONTAINED IN 14 CFR 25-853. (Closed - Unacceptable Action)

ISSUE AN AIR CARRIER OPERATIONS BULLETIN DIRECTING PRINCIPAL OPERATIONS INSPECTORS TO EMPHASIZE THAT DURING A CRASH SEQUENCE FLIGHT ATTENDANTS MUST REMAIN PROPERLY RESTRAINED AND SEATED IN THEIR CREW SEATS UNTIL THE AIRPLANE HAS COME TO A COMPLETE STOP. (Closed - Acceptable Action)

Issued: 03-DEC-1991

To: FAA

A-91-119

ESTABLISH A COMPREHENSIVE EDUCATIONAL PROGRAM TO ALERT PILOTS TO THE POTENTIAL ADVERSE EFFECTS ON FLIGHTCREW PERFORMANCE THAT MAY ARISE FROM THE MISUSE OF PRESCRIBED AND OVER-THE COUNTER MEDICATION. (Closed - Acceptable Action)

Issued: 03-DEC-1991

To: FAA

A-91-120

CONDUCT A DIRECTED SAFETY INVESTIGATION OF THE SUNSTRAND MODEL AV-557 CVR TO DETERMINE THE NECESSARY MODIFICATIONS TO ENSURE THAT THE SWITCHING MECHANISM IN THE UNIT IS ABLE TO WITHSTAND RECORDING TAPE ANOMALIES AND VARIATIONS IN TAPE OPACITY THAT CAN BE EXPECTED TO APPEAR DURING THE NORMAL SERVICE LIFE OF THE TAPE. (Closed--No Longer Applicable)

Issued: 03-DEC-1991

To: FAA

A-91-121

DISSEMINATE INFORMATION REGARDING THE CIRCUMSTANCES OF THIS ACCIDENT AND THE FINDINGS OF THE SAFETY BOARD\'S INVESTIGATION TO THE PILOT COMMUNITY THROUGH OPERATIONS BULLETINS AND SAFETY SEMINARS, SUCH AS THE "WINGS PILOT PROFICIENCY PROGRAM". (Closed - Acceptable Action)